ACO Transitions of Care RN - Care Manager

1400 Baystate Medical Practices, Inc; United States; On-site; USD 90,000 - 122,000; Full time

Benefits offered by this job

Excellent compensation

Health insurance

403b retirement plan

Life insurance

Job summary

Baystate Health is seeking an RN Care Manager for ACO Transitions of Care to coordinate care for a defined patient group, including complex cases, discharge planning, and medication management. The role emphasizes collaboration with physicians and care teams to optimize outcomes and reduce hospital utilization.

The position requires an MA RN license, BLS, and 4+ years of nursing and care management experience.

Qualifications

• Massachusetts RN license is required.
• BLS CPR certification preferred or required.
• Minimum of 4 years of nursing experience with care management preferred.

Responsibilities

• Coordinate and direct interdisciplinary care for assigned patients.
• Identify patients for care management and develop individualized plans.
• Conduct whole person assessments and create self-management plans.
• Evaluate plan effectiveness and revise as needed to meet goals.
• Direct transitions of care from hospital or facility and manage discharge planning.
• Document in medical records and care management systems accurately.
• Provide care coordination face-to-face, home visits, or telephonic contact.

Skills

Care coordination

Interdisciplinary teamwork

Communication skills

Bilingual preferred

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Job description

Baystate Health is seeking an RN Care Manager for ACO Transitions of Care to coordinate care for a defined patient group, including complex cases, discharge planning, and medication management. The role emphasizes collaboration with physicians and care teams to optimize outcomes and reduce hospital utilization.

The position requires an MA RN license, BLS, and 4+ years of nursing and care management experience.